Marlow's Therapy

[Marlow]

Hi everyone. I did a home sleep study (WatchPAT 300) on June 14, 2021 and was diagnosed with moderate obstructive sleep apnea (AHI of 28/hr). I started APAP therapy on July 29, 2021. I have been using my machine every night. I have attached screenshots: the overview of my first 38 days, as well as detailed results from August 31 and September 1. Please let me know if I didn't do it right or if you need other info or more screenshots.

My 2 main questions at this point are:

1. Do you think an APAP will work for me long-term or will I possibly need to upgrade to BiPAP or ASV? It appears almost all of my events now are Clear Airway.

2. Do you think I will need a sleep doctor to help manage everything (especially if I have complex sleep apnea) or can I do it on my own? I do not have emphysema or heart failure or COPD, that I know of. I recently lost my good health insurance. I am now on a much inferior insurance plan that does not cover my sleep doctor. It may be difficult to find a new sleep doctor in-network with my insurance. My sleep doctor recommended an in-lab titration study and said I may have central sleep apnea, as my machine is not reaching full pressure but I'm still having events. Unfortunately, I cannot do any in-lab sleep studies due to severe chemical allergies. So I am hoping I will be able to figure it out using OSCAR.

Also, I was 1 month into a 10-month rental with my DME provider when my insurance changed. It's unclear whether they are in-network with my new insurance. I'm not sure if I'll have to return my machine to them or pay the remaining cost to keep it or something else. I will call them to get more info soon. Regardless, working with them has been quite difficult (45-60 minute waits every time I call, being transferred multiple times, etc), and I might prefer to get the machine & supplies out of pocket on my own. But I need to make sure I am using the right type of machine before investing in one, of course.

I will be very grateful for any help and guidance you can offer. Thank you!

[Sleeprider]

So far, the majority of your events are central. Your event rate dropped when you moved from fixed CPAP pressure at 6.0 to an Autoset pressure with a range of 6 to 16, however your detail chart and summery seems to suggest you don't generally need pressure over 12 cm. Your therapy is marked by quite a bit of flow limitation which is what is driving the pressure variations. I'd like to try using EPR to help with the flow limits, and this may increase your CA event. The only way to find out is to try it. If you're game to try this out, set your machine to Autoset mode, Minimum pressure 7.0, Maximum pressure 12.0, EPR On Full-Time at setting 2. This will give you some bilevel pressure starting at 7.0/5.0 (inhale/exhale) and can vary up to 12.0/10.0. I think you will find EPR more comfortable as it will make inspiration easier. If this level of CA events continues or gets worse, your solution will likely be ASV. It would be helpful to see the detail of your WatchPat study to see the actual breakdown of obstructive, central and hypopnea events.

[Gideon]

Let's see your WatchPat report. I want to see what that indicated for centrals and if it even looked for them.

Please post a 10 minute zoom of your centrals, let's see if we can determine their character.

Set min = max = 9 the see what we can do.

1. Your machine an AutoSet is definitely helping you.

2. By the book you need >5 CAI with OAHI <5 to qualify for an ASV you are marginal here


What machine going forward? I don't know. It depends on the character of the centrals. If these are treatment Emergent then the APAP is possible, otherwise most likely the ASV but not a standard BiLevel. Look at Supplier#2 for cost.

A VAuto has a Trigger setting that is not designed to treat centrals but some users find it useful for treating centrals.

[Marlow]

Thank you, Sleeprider and Gideon. I really appreciate your help. I have attempted to make a 10-minute zoom screenshot of central events from September 1, attached. Please let me know if I did it wrong. I will also post the screenshots from September 2 and 3.

I have not yet made the pressure and EPR adjustments you suggested, though I would like to. I'm first trying to figure out if I'll get in trouble with my insurance or DME. I am on a new insurance plan as of September 1, so I do not have a sleep doctor currently. I see from the Apnea Board wiki that "During the rental period your DME is responsible for the collection of compliance records and reporting your usage statistics" to insurance. Do you know if the DME gets those records directly from the machine, or from my doctor?


Here are the details from my WatchPAT study on June 14, 2021.


Description of Procedures
Unless otherwise noted, respiratory events were scored in accordance with recommended parameters as outlined in the AASM Manual for the Scoring of Sleep and Associated Events, Version 2.6, Chapter IX, Part 2: HSAT Utilizing Peripheral Arterial Tonometry. Unless otherwise specified, pAHI and ODI are calculated using a 3% or greater drop in SpO2 as the definition of a desaturation.

This study was performed using the WatchPat 300. Variables monitored included Peripheral Arterial Tonometry, pulse rate, oxygen saturation, actigraphy, respiratory effort, total sleep time, sleep staging*, body position, and snoring.

Findings
Study was started at 3:19:08 AM and ended at 1:06:24 PM. Total sleep time was 8 hrs, 17 min out of a total recording time of 9 hrs, 47 min, resulting in a sleep efficiency of 84.7%. Indicies are calculated using a technically valid sleep time of 8 hrs, 15 min. REM sleep accounted for 32.7% of total sleep time. The patient slept for 326.5 minutes (65.6 % TST) in the supine position, 169.0 minutes (33.9% TST) in the lateral position, and 2.0 minutes (0.4% TST) in the prone position. Pulse rate averaged 65 bpm, with a minimum of 53 bpm and a maximum of 96 bpm.

WatchPat 300 calculated a pAHI of 28.0 events per hour of sleep, an ODI of 28.0 events per hour of sleep, and a pAHIc of 4.7 events per hour of sleep. The patient experienced a pAHI of 26.8 events per hour of sleep in the supine position, a pAHI of 29.9 events per hour of sleep in the lateral position, and a pAHI of N/A in the prone position. The study also revealed a pAHI of 23.0 events per hour of sleep during NREM sleep, and a pAHI of 38.3 during REM sleep. During the test, the patient spent 1.6 minutes with SpO2 less than 89%, with a SpO2 nadir of 86%.

Scoring utilizing 4% or greater drop in SpO2 as the definition for oxygen desaturation revealed a pAHI (4%) of 24.8 events per hour of sleep and an ODI (4%) of 24.8 events per hour of sleep.

* Sleep staging for the WatchPat 300 is defined as wake; light sleep, deep sleep, and REM. Stages are derived using actigraphy in conjunction with other recorded parameters. Sleep EEG was not recorded.

Glossary
pAHI ‐ is a surrogate for Respiratory Event Index (REI) as well as apnea/hypopnea index (AHI) for the purposes of WatchPat 300 HSAT.
pAHIc ‐ is a surrogate for central apnea index (CAI) for the purposes of WatchPat 300 HSAT
ODI ‐ Oxygen Desaturation Index
ODI (4%) ‐ indicates 4% or greater oxygen desaturation index
pAHI(4%) ‐ indicates AHI was calculated using a 4% or greater desaturation for hypopneas
Technically valid sleep time ‐ total sleep time minus artifact exclusion

Interpretation
Moderate obstructive sleep apnea based on a 4% AHI/REI of 24.8/hour using SpO2 desaturation of 4% to define hypopnea and 3% AHI/REI of 28/hour using SpO2 3% desaturation to define hypopnea. Respiratory events were associated with SpO2 desaturation with a SpO2 nadir of 86%. Time spent with SpO2 < 89%: 1.6 minutes. Frequent snoring was noted. Approximately 66% of time was spent in supine position and 34% in non-supine position (supine AHI 27/hour versus non-supine AHI 30/hour).

Diagnosis (Home Sleep Study): Moderate Obstructive Sleep Apnea – G47.33

[Gideon]

Compliance is ONLY how much you use the machine. Thus your Insurance doesn't care.
You will find your medical team VERY slow to respond and make changes, you can help this by complaining a lot, Min frequency of complaint is once a day to both your doctor and your DME.
Your DME CANNOT make a change to your machine without a change in the prescription from your doctor. You can. Frequently when you do they will say Stop, Don't do that, you may blow up your lungs and initiate a chain reaction that will reduce the Empire State Building to rubble. They won't say that but you causing a building to come down is as unrealistic as you blowing out a lung.
The fact is that until you know what you are doing making changes are as likely to hurt your therapy as help it, and nothing will be deadly.

So for now, CALL your DME and tell them this isn't working what can you do to make it better and get rid of those pesky CA events. Then call your doctor and ask him the same thing.

[Sleeprider]

WatchPat apparently did not document any central apnea in the diagnostic study, so we have to assume these events are treatment emergent. As I said in a previous post, flow limitations are prominent in your therapy and EPR is the best cure. This may make CA worse, but I'd still like to see how you respond to the settings I suggested earlier; Minimum pressure 7.0, Maximum pressure 12.0, EPR On Full-Time at setting 2. This will give you some bilevel pressure starting at 7.0/5.0 (inhale/exhale) and can vary up to 12.0/10.0. I think you will find EPR more comfortable as it will make inspiration easier. Since CA is not a feature of your diagnostic study, I'm sure your doctor will continue to observe your CPAP therapy for at least a month. The normal expectation for therapy onset CA is that it eventually diminishes in time. Your AHI is considerably lower with CPAP than your diagnostic study, but not within the limits we hope for.

[Gideon]

Sleeprider the OP posted watchpat results of pAHIc of 4.7 events per hour. Vs AHI of 28.

So IMHO we will likely see some Idiopathic CA.

Plug in SR's settings and see what we get. We will learn a lot.

[Marlow]

Thank you both for your responses. I do not currently have a sleep doctor due to my insurance changing on September 1. Thus I do not have one to call or to observe my therapy. I am working on getting a new sleep doctor, though it may be 1-3 months until the 1st appointment. I also do not have a primary care doctor until September 22.

I would like to make those pressure & EPR adjustments suggested by Sleeprider.
My question is: Will making those adjustments myself cause me to "get in trouble" in any significant way - meaning, will my insurance stop paying for my machine, or will my DME require me to return the machine?

The "Plan of Service" I signed when getting my machine from the DME states:
"Patient will receive and use equipment according to the physicians prescription"
"Patient will understand that all consultations and changes in therapy must come from a physician"

The "Acknowledgement of Medical Responsibility and Informed Consent" I signed states:
"Patient is under the supervision and control of an attending physician"
"Patient's physician is solely responsible for diagnosing and prescribing the items or other therapies for patient's condition and otherwise for controlling patient's medical care"

It doesn't say what my DME, doctor, or insurance company will do if I make pressure adjustments on my own. I would appreciate any knowledge you may have on that aspect. Thank you very much.

[Gideon]

Generally they take credit for all the good things we accomplish, and say don't do that.

This will not result in taking your machine away, and as long as you use it your insurance will continue to pay.

[SarcasticDave94]

They very likely are not going to notice, unless you're like some sarcastic guy named Dave and bluntly told them he's changing the setting as the ones that doc chose were ineffective. Otherwise all will be "everything looks good, you're using the PAP 100% of the time." All while CA are at 99, or a 2 minute Apnea, or whatever other trainwreck you want. In other words they don't care one bit unless you don't put time on the PAP.

The WatchPat info stated "respiratory effort" so I'm guessing it was an effort belt or similar, meaning it should have caught CA, appears it had some listed.

Note do not blow out your lungs by turning that dial. That type of injury isn't covered.